Provider Demographics
NPI:1700598356
Name:WYSOCK, SAVANNAH FAITH
Entity Type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:FAITH
Last Name:WYSOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1811 GRAND CANAL BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-8107
Mailing Address - Country:US
Mailing Address - Phone:209-452-8996
Mailing Address - Fax:
Practice Address - Street 1:668 MAYTEN DR
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94551-6186
Practice Address - Country:US
Practice Address - Phone:925-719-2697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-14
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst